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11-22-11
`~ 1505610105 REV-1500°"°Z_11"F" lvania OFFICIAL USE ONLY PA Department of Revenue PennnsY County Code Year File Number Bureau of Individual Taxes "`""`""~"f """"""" Po Boxzso6oi INHERITANCE TAX RETURN .~ ~ ~ 1 ~~'r- Harrisburg, PA ipu8-o6os RESIDENT DECEDENT }" ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 165-58-0963 02126/2011 10!12/1962 : Decedent's Last Name ... .....Decedent's First Name MI Sutra...... Fritz Jeffrey f A (If Applicable) Enter Surviving Spouse's Informatlon Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's social Security Number _.. . THIS RETURN MUST BE FILED IN DUPLICATE WITH THE _ _ - _ _ REGISTER OF WILLS FILL IN APPROPRUs.TE OVALS BELOW (~ 1. Original Retum O 2. Supphementat Retum O 3. Remainder Retum (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of VJIII) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credft (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 1231-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0. Name Daytime Telephone Number .Jordan D. Cunningham (717) 238-6570 First Line of Address 2320 N. Second Street Second Line of Address CKy or Post Office Stale ZIP Code Harrisburg PA ' 17043 REGISTER OF . ~~f~USE ONLY:;'_ f. __ t _ tJ I'J °--:~: C;~.~ i~ CJ<_ _ .) (..,.` DA ED ~~ Correspondent's s-mail address: Under penalties of perjury, I declare that I have examined this rotum, including accompanying achaduka and statements, and to the beat of my knowledge and belief, k fs true, correct and compote. Dedaretbn of pro aror o than the personal roproserrtatMe is based on aN irriormetlon of wh~h proparor has any knowledge. SIG~U ~OF PERSON.RESPONS L F SLING ETURN ` / ~,Z ! 1 ! ADDRESS 106E o a ~ e, Mechanicsburg, PA 17055 SI TUR R OTHER THAN REPRESENTATIVE AD SS 0 N. cond Street, Harrisburg, PA 17110 Pr`eASe use 15056101D5 DATE Side 1 FORM 1505610105 ~~ r -:) <, .3 ,- , : 7 i __) _ ..~ r--. ~ ~~i _~ t -- __:J .~ ;`T1 ~n ..r.i J 1505610205 REV 1500 EX (FI) Decedent's Social Security Number Decedent's Name: '. 165-58-0963 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2.1 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ~_. o".q~M d,_a_ ~_. ~m.~ ~.~ 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 8,307.43 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. i 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property ~~ 5 210 06 (Schedule G) O Separate Billing Requested........ 7. , . 8. Total Gross Asssts (total Lines 1 through 7) ........................... . . 8. ; 13,517.49 r 9. Funeral Expenses and Administrative Costs (Schedule H) ................. . . 9. 11,549.24 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. ' 3,781.00 s 11. Total Deductions (total Lines 9 and 10) ......... . ..................... . . 11. 15,330.24 12. Nst Valus of Estats (Line 8 minus Line 11} ............................ . . 12. `, -1,812.75 13. Charitable and Govemmsntal BequestsiSec 9113 Trusts for which "° ~----- ~~--` --°°•-.,_..__...._.._......~,._~..~.__.~.~ an election to tax has not been made (Schedule J) ....................... . 13. 0.00 a~ ~,"_m ~ , _. ~. ~.~ . ~~ a "~~ ~".~ 14. Nst Value 8ubjeat to Tax (Line 12 minus Line 13) . ....................... 14. ' 0.00 ----- - - - TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 _ _ __ (a)(1.2) X .0~ _ 15. 1B. Amount of Line 14 taxable ° ~'" ` ".._ .-a.n"~ .m~...... . ".",r..,_.. , at lineal rate X .0 45 0.00 16. ._,_..,.. ..w _..~.,__...,_ 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable .._~ .~...._._....~......w......_._..__.._~.__, ~___.___~ at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REpUEBTINt3 A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 REV-1500 EX (Fl) Page 3 Fik Number Decedent's Complete Address: DECEDENTS NAME Jeffrey A. Fritz STREET ADDRESS 65 Hummel Avenue CITY STATE I ZIP Lemoyne PA ~ 17043 Tax Payments and Credits: 1. Tax Due (Page 2, Lina 19) 2. GrediLslPayments A. Prior Payments _ _ __._. __.___ _ .. _____._ B. Discount 3. Interest (1) 0.00 Total Credits (A + g) (2) 0.00 (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the properly transferred .......................................................................................... ^ ~ b. retain the right to designate who shall use the properly transferred or its income ............................................ ^ c. retain a reversanary interest .............................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12,1982, did decedent transfer properly within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "intrust for' or payable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an indmdual retirement account, annuity orothernon-probate property, which contains a beneficiary designation? ........................................................................................................................ ~ ^ tF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN, For dates of death on or after July 1,1994, and before Jan. 1, 1995, the tax rete imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent (72 P.S. §9116 (a) (1,1) (i)). For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent {72 P.S, §9116 (a) {1.1) (ii)). The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 172 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+ (11-10) Pennsylvania SCMEpYLE E ~.il DEPARTMENT OF REVENUE {r/~SH~ BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Jeffrey A. Fritz Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survlvonhip must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Members 1st FCU (Mr. Fritz's Acxount transferred into Administrator's Members 1st Account) 1 285.43 2, IRS Income Tax Refund (2010) 1,087.00 3. Rent Security Deposit 490.00 4. 2002 Honda Civic EX {Payment from sale of vehicle placed in Administrator's Members 1st Account} 4,500.00 5. Miscellanous Personal Property a. Various United States Mint Proof Sets for 2002-2004 120.00 b. Baseball and Football Cards (unsorted and un-inventoried) 150.00 c. 86 Wheat Pennies of various years in the 1950's 5.00 d. $6.00 of Eisenhower Dollar Coins 10.00 e. Clothes and miscellaneous hunting gear 250.00 f. One single shot breach loading 12 gauge shotgun 95.00 g. Various foreign coins {brass and cooper) 20.00 h. Various silver and copper quarters and half dollar U.S. Coins (wight of silver used for valuation as 295.00 all coins were from the 1950's and early 1960's and in poor and rough condition and none had collectible value) -- TOTAL (Also enter on Line 5, Recapitulation) ; 8,307.43 If more space is needed, use additional sheets of paper of the same size. .a~~ ~ ~ ~ ~ ~ ~" A ~ ~.. +, ~". 'd •v a ~~ ~ ~~ g ~~ 9 ~ !'~' i V {./ (~ \,~`-' i i r /~'\ V'` f {, '_ -,- ~,;~- ~ ~~ {,. ~ - `~ ~_ ~- ,1 .~ ~ ~ '~ i ~. ~"' ._ --- .,..~~_ c v U' 3_ a~~ ~. ~. ro w 1 ~~ ~~ MEMBERS 1St FEDERAL CREDIT UNION Send Inquires to: 5000 Louise Drive PO Box 40 Mechanicsburg, PA 17055 www.memberslst.org Main Switchboard: (800} 283-2328 EZ Call: (717) 697-4372 or (800) 283-4372 TDD: (717) 697-5312 or (800) 283-2328 ext. 5312 TeleBranch: (800)237-7288 b459 1 AV 0.335 22394-6459 *.~ I~~~III~~~lll~~~~l~l~~l~i~~~ll~r~ll~l„~I,~I~III~~~~II~~„~III ~~ BONNIE S FRITZ 106 E WOODLAND DR ~~ MECHANICSBURG PA 17055-3372 ~~ ~~ .~ Statement of Accounts Feb 25, 2011 thru Mar 24, 2011 Account Number: 48596 Balances at a Glance Checking : 11,459.64 Savings : ~ 357.50 Certificates : 0.00 Loans: 0.00 Money Management : 6.67 Swipe 5 YTD Reward : 0.35 Page : 1 of 3 Your current Member Loyalty Rewards level is Gold. Your aggregate balance as of March 1st is $18,526.94. An aggregate balance of $35,000 and having 3 products will move you to the Platinum level. National Credit Union Youth Week is April 17-23. Celebrate the week with us! See the enclosed insert for more details. CHECKING ACCOUNTS 001 i - CHECKING Date Trnnsactlon Descxrotion Additlons Subtractions Balance Falb ZS BeA Fon~raM 16,434.47 Joint Owner: RONALD E FRITZ Feb 25 Withdrawal POS ;!1867859 99.50- 113,334.97 GIANT FOOD ~K331 MECHANICSBURG PA Feb 28 Deposit by Check 2,044.08... 18.379.03. Feb 28 Check 008332 Tracer 0021434693•.. 32.50- 18,348.53 Processed Check -:PATRIOT NEWS' TYPE: CHECK: PYMT !D:" 0480001263 DATA: 0000012300 041204975' Feb 28 Check 006333 Tracer 52Q7932330 71.38- 18,275.15 Processed. Check - ATB~T SEFF~~VICES TYPE: CHECKPAYMT ID: 172782655 ' Feb- 28 Check. 006338 Tracer 0001&13680 ~ .) ~ '' 140.00• 18,13!3.15 Feb 28 Deposit Dividend 0.10096 ~` 0.88 18,135.83 Annl~iell Ps~raerri~rje Y~erld Famed Q. tarl%'lia7m /0>/22ft dtaw,gih Q2/28/2(~t Based on Atertggie ~1' B~irras at B, 917.41! fir. Mar 04 Check 008337' Tracer 0001314291. ~ 1,395.00- 16,740.83 Mar OS Withdrawal P03 ~18t11800 6 rt ~ 62.35-' 16,878.48 GIANT 6331 MECHANICS ~ Rt3 PA ;' ~. Mar 08 Check 0013338 Tracer 0001565869... ~ e~ ~ 6,777.74- 9;900.74 Mar 09 D sit: b Check ~ ~, ~ Y 2,168.57 12,067.31 Mar 09 Withdrawn! at ATM X38584 ~ r;,`-' - _ 202.78- 11,864.56 CITIZENS. BANK ~` T/~L (- P„~- ' Mar 10 Withdrawal at ATM #/0073""'1' ~, - ~ ~~~~~~~~~~ 200.00= 11,664.56 MEMBERS 1ST FC 4 Pf M HANICSBURG PA Mar 15 Check 008339 Tracer - ~ 'lb~~~~L ..~. ~_.: ~~ ~ ~ ',~°=~1i:.~i~a 39.01- 11,625.55 Processed Check - VERIZON ARC TYPE: CHECK PYMT ID: 2.005022221 DATA: DATA Mar 15 Check 006340 Tracer 0027346156 48.43- 11,577.12 Pracessed Check - VZ WIRELESS ARC TYPE: ARG ID: 2005091202. DATA: DATA Mar 15 Check 006342 Tracer 0128580619. 220,82_ 11,358.50 Processed Check - UGI UTILITIES ~ ~ ~~ I.J TYPE: UTIL PMT ID: 231174060 ___. -~--~~ry`\.-, ~-- Gontinuedoll6~i L..,y.....~.~ ~.. i~ ~~ ~ooo~ 5 6 3 3, 9 3 3 9 0 r 8 •,.~:: r ~'''~ G'~eck Nn. ~ OS 04 11 4g AUSTIf~, TEXAS" 231073906225 20090900 I30~ ~~ ~~231~0~.73906225~~.~~ ~~ Pay to ~ L~~III,~~III~~~J,i,~i I IL~~II~I,~,I„LIII„~II L,~IFRIt- KaN~;' ~YTAX REFUND ' the order of ~ n~ BONNIE S FRITZ = ~~~~ ~ - JEFFREY A FRITZ'~DECD ~ ~~~~ - ~~~T~ _.. 106 E WOODLAND DR= MECHANICSBUR6 RA ~~ ~ ~ ~ ~~~ ~~ 17U55.337Z' g***1.087*00 asoip„'y,p,~,~~~~~ VOID AFTER ONE 1'fAR i 454 ui 1 _ ~.OODOOD 5 i8~: 7 3906 2 2 58n - -_.-- ___- _ _ 04051E ` BRIDGEPORT PROPERTY MANAGEMENT, LLC. BONNIE FRITZ ~~ ~ ~-Yo ~~v CHECKING-COMME 65 HUMMEL AVE RETURN S/D 65 HUMMEL AVE 4/1512011 1450 490.00 490.00 ~-~ National Edition 1992 THROUGH 2003 PASSENGER CARS LIGHT DUTY TRUCKS MILEAGE TABLE ' YAl@I tN0E7N EELOW TO EI MJYETEI -R0M EASE /YIOEINE YAIUEE INet --7f- 2950 175 2500 S 23 2575 2 IA -I~~l7 30 0 _ 00 715 3200 325 3 lp/le 10 fl 11 4 Y 5925 Sp75 5760 5/2S 5900 591 8 + I) 1 26 1150 1 IEen ~g¢26 y ~'~ zeoo-'2es~o'-"29o~a I/NI 1 ] 825 3 1 3 2 ~ ]77~"-3~tfA a r Ir33 ~f2s- s2oo s2r s]so s1~ •~ ,' I/Oet 19 I IA ^ 111 2221 1 IE/el IY 2j 0 3 S0 .~3~,jiL~ ~ 4 ] ~I~ 422 1575 I9~50 1723 1100 . 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Si) 25O 2N A 2062 M• MM CtEES M a 2 ~ 46NCaps2DUC CG3{))(} 198902967 I 1 ~ N7i 11N 43N 4626 COUpl2D u((t~l. CG22 22600 3276 NN IBN 3726 1226 4661 Ccupe 2D SE . CGJ2O 10850 2987 IIn 7111 3171 4321 5671 Coups 2D EX SGII)Q 21500 YlU 1675 T72f 70{ 412/ SeN Caq 2D EX IV6) . CG225 25300 3287 StIN 7121 1400 7221- 39H Slgan 40 DX ... CF&µ 15500 2913 7525 5611 26N 7126 ItOf SedanlD vacua CFS 17700 2947 7701 62N 3025 ]9N 4/21 Sedan 401X.. CGINHj 1&8903035 1171 ftN 7]N 4201 1921 Sedan 40 LX {VB) CGi 12800 3274 1100 7161 3126 x321 507!$eWn40 SE CGIiB( 20850303+ 1671 7721 3501 412! 3+71 Sedan 40E%. CGf)(p 2+5003087 1075 7161 ?!n N2f 3705 Sedan W EX(V8) CGt 25300 3329 6161 6821 126 ANAlun4nunuAltoy Wheels ISro Auoro SEER) 125 131 200 ANLeaRer Scab fSW. Accord EX V6) IOI ANPwtw SeaiiStl.Aaortl V6) 1 N 125 !Oe Op01MMW7oulAirConmlwnnq. 301 7N 701 OEt1pEt WNNR AuWma6C franX 301 3N 2002i281fiCt1{.i 31L MNp~p CtEf* I• SfSO 7071 9e76 RoaWW 257 ;+ptU 32400 2606 727! tOON Sze ANDsbMaW Nardtop 510 661 HORf1 2081 Wr1G•4 CM• MNEpOE DYES 1 X026 2730 7361 Ccupe 20 Ox E4i2g2 !.760 2405 7020 52N 2326 3076 3761 Ccuoe lD NX ."32117 t-X5602434 33N 5825. 2376 332! 3730 Cwpe 10 LX E'A2115 14850 2465 377E 5178 2frS 3168 qlN Cnupe~DEX. c!.12~19 ty4102553 37M Be71 ADJUST FOR MILEAGE 'ANOAIIY fNN0U0N AfRI1201/ l~l~ ~' MEMBERS 1# P&DEAALCaanrr ur~ON P. O. Box 40 Mechanicsburg. PA 17055 Return Service Requested ~f, 5 o c St 1VIEMBERS 1st FEDERAL CREDIT UNION Send Inquires to: 5000 Louise Drive PO Box 40 Mechanicsburg, PA 17055 www.memberstst.org Main Switchboard: (800) 283-2328 EZ Call: (717) 697-4372 or (800} 283-4372 TDD: (717) 697-5312 or (800) 283-2328 ext. 5312 Telet3ranch: (800) 237-7288 6495 1 AV 0.340 23020-6495 r I~~~IIf~~rIll~~r~LI~~I~Ir~rI1~~~ILI~~~I~~{.INr~~~ll~~~-Jil --~ BONNIE S FRITZ 106 E WOODLAND DR ~ MECHANlC5BURG PA 17055-3372 ~~ -~ r= Statement of Accounts Mar 25, 2011 thru Apr 24, 2011 Account Number: 48596 Balances at a Glance Checking : 27, 715.58 Savings : 357.58 Certificates : 0.00 Loans: 0.00 Money Management : 6.67 Swipe 5 YTD Reward : 0.35 Page : 1 of 3 Your current Member Loyalty Rewards level is Silver. Your aggregate balance as of April 1st is;11,387.56. An aggregate balance of X15,000 and having 3 products wilt move you to the Gold level. Would you like to receive your statement faster? Sign up for eStatementst Go to Members 1st Online, click on the eStatements tab and provide us with your smolt address CHECKING ACCOUNTS OQ1t -CHECKING Date Transaetlorr Deecric>tior- Additions Subtractions Balance A~ler 25 Fonvatd 11,499.64 Joint:Ownerr_RONALD E FRlTZ Mar 28 Withdrawal RQS #781936 56.31- 11,443.33 GIANT 8331 MECHANlCSBURG PA Mar 28 Check. 006343 Tracer 00011500 20.00- 11,423.33 Mar 30 Mar 31 Check 008362 Tracer 0001078577 {~ Check. 008363 Tracer 0001251975° ~ 114.05- 322.65- 11,309.28 10,988.83 Mar 31 DeposR Dividend 0.100°,6 ~ ~ 1.11 10,987.74 Annra~l Pslrtaenfage Yaak1 E~rrl'ed 0.1AOX fiam at?/01/ZID1f fhrotryh U3/3111n11 -~' avr Atrorlr~l- ~1' Bae- ~ 13,OiB.319 Apt 01, ,. _; Deposit by~_Cheek; 4,500.OU 15,487.74 Apr• 01 Deposit b~,Check-. _ 16,374.48 Apr 02 Withdrawal at ,4TM *17 200.00- 16,174.48:. MEMBER'S 1ST FCU 5000 LOUISE DR MECHANICSBEJRG PA Apr ~ Withdrawal P03 1rISi5156 52.62- 18,121.86 GIANT 833.1. MECHANICSBURG PA ` Apt 04 Withdrawal at ATM 11t)409A4 303.00- 15,818.88 GCA' HOtLYWOOQ= CASINO A GRANTVILLE PA Apr 05 Check 008366 Tracer 0001273119 41.50- 15.777.38 Ap€_05 Cheek 006364Tracer 0001288859: ~ 193.82- 15,583.54 Apt. 08 Chedt Q08361I~ Tracer 0001082482 69.51- 15,514.03 Ap- Oli .Withdrawal Pfy3 X1383 ~~ - ~ 54.79- 15,459.24 ~ GIANT' 6331, MECHANICSBC~'2C~ P, `` ~ Apr 08 Withdrawal at ATM !1006672'" "' .~ i 200.00- 15.259.24 . _. M~MBER3 1ST FCU34 MAl2KE'1 PLAZA WAY MECHANICSBURG PA Apr 09 Withdrawal P03 1180283'2 23.20- 15,236.04 GIANT 833'! MECHANICSBURG PA Apr 11- Deposit by Check 25,059.30 40,296.34 Apr 11 Withdrawal POS #145910 97.86- 40,197.48 WEGMANS 8416 CARLISLE PIK MEGHANICBURG PA Apr 12 Check 006357 Tracer 0026446197 39.50- 40,157.98 Processed Check - VERIZON ARC 'TYPE: CHECK PYMT ID: 2005022221 DATA: DATA --- Continued on following page --- REV-1737-6 EX + (6.08) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN NONRESIDENT DECEDENT scNEOU~E a INTER^VIVOS TRANSFERS & Use Schedule G, Part 2, ONLY for Misc. NON-PROBATE PROPERTY proportionate method of tax computation. ESTATE OF FILE NUMBER Jeffrey A. Fritz Part 1 must include all transfers of real estate and tangible personal property located in Pennsylvania. Complete Part 2 ONLY when the proportionate method of tax computation is elected. Include in the description of property the date the transfer was made and the name and relationship of the transferee. This schedule must be ~mpleted and filed if the answer to questions 1 throu gh 4 on the reverse side of the REV 1737 cover sheet is yes. DESCRIPTION OF PROPERTY ITEM InGude the name of the transferee, the relationship to Decedent end the date of transfer. DATE OF DEATH °k OF DECD'S EXCLUSION NUMBER Attach a of the deed far real estat®. VALUE OF ASSET INTEREST IF APPLICABLE TAXABLE VALUE 1 ~ Shelby Group - 401(k) Plan {Vested) 5,210.06 100 5,210.6 PART 7 TOTAL : ~, a 5,210.a ., .~ DESCRIPTION OF PROPERTY ITEM InGude the name of the transferee, the relationship to Decedent and the date of transfer. DATE OF DEATH % OF DECD'S EXCLUSION NUMBER Attach a Dopy of the deed for real estate. VALUE OF ASSET INTEREST (IF APPLICABLE) TAXABLE VALUE 1. PART s TOTAL 3 $ 3 0.« TOTAL (Also enter on Line 7, Recapitulation.) ~ s 5,214.06 (If more space is needed, use additional sheets of paper of the same size) ;~~~~-IUt~,L ~A"rf~rlfNT ~~;nuary 1, J00~~ - December 31, 2009 SHELBY GROUP EMPLOYEES PROFIT Contract Number: 440907 SHARING 401(K) PLAN Identification Number: xxxxx0963 This Year The change in account balance reflects Beginning Balance $3,004.65 gain/lass in value as well as account Additions 3,113.15 transactions, which include additions, Fees -- withdrawals, fees, and transfers. Gain/Loss 1,717.46 Ending Balance 57,835.26 The Personalized Rate of Return (PRR) represents the performance of plan assets Change 54,830.61 held for your benefit for the time period of Personalized Rate of Return 35.29% this report. The PRR is based on your specific account activity. Past performance Vested Balance $5,210.06 does not predict future results. The vested balanie is the amount that you would keep if you separated from your employer now. Your vested balance will be Contributions the same as your account balance on 20 2 08!14/ 1 . Since Joining This Year Your employer is helping you to save for retirement by making these contributions on Contributions made by: your behalf. You $3,242.77 $1,432.35 Your Employer $3,821.81 $1,650.98 Your Plan Sponsor is paying for a portion of Total Contributions S7,o84.S8 S3,o83.33 plan fees. Plan participants are also paying far a portion of plan fees. These amounts may differ from those on your pay stub when some contributions The underlying investment options also have fees. For these fee ratios, see your have not yet been posted on your account. prospectus or other investment material at www.principal.com. Page Z of 1 D Account Balance , REV-1737.6 EX + (6.08) REVERSE `~~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RENRN NONRESIDENT DECEDENT ESTATE OF FILE NUMBER Jeffrey A. Fritz Debts of decedent must be reported on Schedule 1. fTEM NUMBER DESCRIPTION AMOUNT q, FUNERAL EXPENSES: ~~ Neile Funeral Home 6,777.74 2. Rolling Green Cemetery -Grave Site 1,615.00 3. Rolling Green Cemetery -- Headstone !Grave Marker 1,668.00 4. Rolling Green Cemetery --Cemetery Interment Rights 1,395.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commission(s) Name(s) of Personal Representatives} (Submit requested information for additional personal representative's on additional sheets) Soual Security Numbers} or EiN Number(s) of Personal Representatve's) Street Address(es) City(ies} State(s) 21P(s} Year(s) Commission Paid 2. Attorney Fees 3. Probate Fees Register of Wills 4. I Accountant's Fees 5. Tax Return Preparer's Fees 6. Miscellaneous Expanses TOTAL ~Atso enter an Line 9, Recapitulation,) ~ f mare space is needed, use additional sheets of paper of the same size) s~Nlo-uL! N FYNlRAL !XPlNSls ~ ApMiNISTRATIV! COSTs Use Schedule H ONLY for proportionate method of tax computation, 93.50 11,549.24 Neill Funeral Home 03/07/2011 Bonnie S. Fritz 106 E. Woodland Drive Mechanicsburg, PA 17055 SECTION I SERVICES AND MERCHANDISE FUNERAL DIRECTOR AND STAFF SERVICES Minimum Professional Service $ 2,995.00 CARE AND PREPARATION OF REMAINS Embalming $ 795.00 Other Preparation (Casket, dress, cosmetic ) Refrigeration USE OF FACILITIES 8 RELATED STAFF CHARGES Visitation Funeral Ceremony $ 395.00 Church Ceremony Graveside Service TRANSPORTATION Transferring Remains to Funeral Home _ Funeral Vehicle -Hearse LimousinelFamily Vehicle J_ ServicelFlower Vehicle _ Transfer to Crematory MERCHANDISE Casket $ 795.00 Outer Burial Gontainer $ 995.00 Alternative Container Urn Other OTHER GOODS AND SERVICES Memorial Book 8 Prayer Cards Memento Box Crematory Aftercare Planner Helpline Services for: Jeffrey Fritz Service Contract: 741101000236 Date of Service: March 3, 2011 SECTION II CHARGES MADE ON YOUR BEHALF Patriot News Obituary $ 617.74 Medical ExaminerlCrem Authorization Certified Copies of Death Certificate $ $0.00 Clergy J Honorarium $ 125.00 Musicians (organisVsoloist) Hairdressing Cemetery TOTAL SECTION II $ 802.74 SECTION III OTHER Insurance Allowance Dignity VFW Discount Dignity VFW Components Discount TOTAL SECTION III SECTION IV TAX TOTAL SEC710N IV TOTAL CHARGES Less Insurance Payment of Less Payment of Balance Due $ - $ 6,777.74 $ - i ~'~_ - t l\J . TOTAL SECTION 1 $ 5,975.00 Digniry~ 3501 Derry Street • Harrisburg, PA 17111 • 717-564-2633 • Fax 717-561-9918 • Stephen J. Wilsbach, Sup. 3401 Market Street • Camp Hill, PA 17011 • 717-737-8726 • Fax 717-737-1859 • Kevin J. Shiltabeer, Sup, DignityMemoriaLcom f.~r-...~/.Vw'~~.~..+.F,..fI~fAA~wwwiw+try4+v.vr-..r.+.n .r. ~"~a~r`~ .. .P i - ~~~~ "v»7+~ r~-•esT~fi A~rIMP~M4-'r`'ti!'~i~~fa•~«f,r~•.r-f+.~+er`rtl w•r^r-~-+ yry. •.~'.! ..~. ~- ~ ~~~ .~.J! -4 i ~Jl •.I~-, .Nf ,-.J --JM a ~.v.,~~...~.hf-J~i 5t+~' .r.1~..~ .. ' •~.r i.. ~.:~i Y ~!. .y. ~.~. r' r •*. J... r f 43 .~~ffr ~ +f .! ~ ~ r _ - . ~ • z.~ h •k~ • .K..:. q. N,. ~'...! r . ~ r.. r ~ ~ y,.. y. ~_ ... « +a! ,, y , } .%.Ir"~.. ~~1 rtJ~7~. •1.~'-=,iT.r7 I~ ..~. ~ i- .f':.Y. ~...j wMI~VV/a..Y `.`T}'~~. .. ~n.r •• ' rs{r'?`='=:~r~~~ts,~~•,r.~rars~u-~r~:a+.e~~tcr~tis:''aaec~r•~~rs: ~srai°r arses ~f'` , s~ Jwuic+s,.riv~~„+wv~ rt::rtr.a ..Js.~ ~ ~'"!~"?.. '~!!"?!..~C~R=~tic~ ~ Y~l~s~wiwf' fi~Vlifiiir L~If~l~/~flr r. ~n~CM.~~'~r rM71C~'iN~+ ' ~,(.,,,luflW~M'.+-•W+... ~..f... `..iw~i~t._~_.... ... .._ .d i..i~^iW.irAr~ ./~ :,,~ ^r1i`.~`m•ir,i/•~ y ~ A• w. r•f. ..r' _ y J~/~ .. .~+ .f..1. +~'0 f ~86,~M ~036A'~6 i SDI: i ~ 1~4 f 4Q6'q[t~" ~.~ 12862 12,'15201 ~ $1 fit x.00 R4LLfN~3 GRF1~N CEMI~AY C©MP1kNY 1Rff CARUt1L4e ROAD • CAlAP Nltl, PA 77Rtf ' t71T) 76t•d0~ Conttmct CEMETERY INTERMENT 1 THIS AGl ~~.~ i ,~. File Foltier NarnclNumber AND SERVICES PURCHASElSECURITY AGREEMENT 'fhe uadendgaed, rcraree/ is a 'Psrchsrrer'• hereA~ agree to parehue tM TntenaeM Righp• Merehaadhe ad gurleu deeerl6ai hells. wbjeet to scaptaaa ssi apprsva{ sa Ii! ahDY! M1111'd enttetfry harasser rchtred H H •$etitr•. Purehsaer: Last Name:. ~$~'r ~1 J i! I I 1 1 1 i 1 1 I 1 F"r' Q~ ~l~~d ~ 1 1 I i I 1 I t M~k' (_1 I I l I. 1 Telephone: (~I~) ~_.~ t~ 4 3 SSN: _ DOB: ~ J~,- 1 Email: Address: t n ~ r a soon, sst nt tOMlt r t t i ! t t t ! ! eery: n ECUt RIlt11 CS. dU £Qs~O!" ~>Q i Zip' { ~t?.[S Co•Purehaser. Lan Name: L I 1 1 1 1 1 1_ 1 1 1 1 1 1 1 1 1 Flrnc I I J 1 1 1 1 1 1 1 1 1 1 Middle: 1 1 1 I I I I Telephmre: ('} _ SSN: _ DOB: _~__ J Email: `~t°""` I I I I I I I I i l l I l j l l ~ 1 1 1 1 1 1 1 1 1 City: 1 1 1 1 1 1 1 1 1 1 1 1 1 ~n•' 1~ f Zip: Ocecaeed: Last Name: ~(Z 1 7 ~,, I J 1 I I f 1 I I I 1 1 I Flr"t` ~~~~~ t; h' 1 1 1 1 1 I _l M~k° ~ I 1 { 1 1 I 1~8: i r~ /_~~~ DOP: ~ ~ (,, I~ 1 Burial Date: !~__1 vneroa: Deteripttan of IMermenl Riahta l0 6e Bred: MerawlalMlbrt Rights: Issue Cerrificnte of Imermem Rightr ro: AdSress; City: State: Zip: • fntertneM Rights S (Includes Perpetual/Endowment Cate of S ) • IMermertt and Recording Fees "' • Outer Rurlnl Container Supplier Modellt)esign MateriallColor • Outer Burial Container lrxstallatMa "~ 6iF.MOR{ALI2ATION Supplier 4-'le~(•i~(-J ~ TypelColor S•}-nxi• - r DesigntSixe ~4 ry14 ~ o.1~.t.-~oa..A.. • MemoHa! Rase~=y~~~ °~~ • ~ Supplier M ILL-ass C TypelColor ~riGl1 rr- Design/Siu .D •~ ' ~/ i A • Memorial Pcrpetnsl/EndovrmeM Care 3e2 FC .Q7 • Memorial Inatallatba Fee • Memorial tnspectbn Fee • NemeplateiScroll '~ • Lettering • Flower Yase Supplicr TypelColor [ksignlSize • Yase Rase SimlMatcrial Notes 6i Payment Terms (where applkabk}; Total IMvrn Payment (J.yya,sy_y,.}_ ) Unpaid Balantx d Total Cash Price S n The Total Cash Pries is due and payable as of the date of this Agreement. A delinquency charge of percetrt will be asaeared monihiy on any balaaca teat paid within 30 days of rile date of this AgrteitneM: I[ lets than fulFp6ymem i3 rtceived, Sblkr shall dsttact the accrued delinquency charge from the amount received sad crcdN the remainclcr of the paymem to the Unpaid Balance. .Security lnlsrest: Sclkr (a hs assigns) will have s security interest in the Interment Rights and Men;handire being purchased as described above. Seller will remin titk to said Intermem Rights and Merchandiu until the Total Cash Price, together with any delinquency charges thereon, have been paid by Purchaser to Seler. NOTICE: By signing this Agreement, Purchaser it agreeing that any claim Purchaser may have against the Selkr shall !x resolved by arbitration and Purchaser it giving up hislher right to a court or jury trial as welt at hislher right of appeal. Signed this ~" day of ~ssa, Q , ZO 1 /_ _ ~' .r. `J_'t Purchaser:~~ ~. ) ~nti._.1-~~.- ~ Relationship: 1M O _a i • Urn _ Supplier _ 'type/Color DesignlSiu • AdminlProcessing Fee ~ ~ • ~ • Other • Other _ • Otber _ • Other • ~~ - • Other TOTALS, ALLOWANCESdtTAXES • Interntest Rlghta ............................................................... ( - ) Reaaat • Meechandlae/Servlce ........................................................ ( ~- ) Reason _ Apply to • MerchandbelSerrice ........................................................ ( ) Rcason _ Apply to _ Sub Tatal ~ ~n~ . Total Taaabk '- • Sties Taa Iii appltcabte) ................................................... ~ . .. 1 ` TOTAL CASH PRICES ~ n %. R • CIO Leas: T)osrn Payment 1~(Qg,,(~ raw.. !I'Ci PI!NI~YLrYANtA FUNRR.4L ~~~I;llr IN+CI. dRlt @104~.IMA itR~N 4EN1 Accepted by; 1 utreM thx 1 fire rtrfewrd Nix,hcamem InrarCUnty and aawptel<nexa Co-Purchaser: Relationship: Date: _JJ' ,~ ~/' ~ Counselor_ y1 ~ -~ ~`„p~_, ~ • r M t ! i / `~ ~fwe NOTICE: See Other Side for Additional Terms and Conditions which are Parrot This Agreement i~J.iW~l1 tii1 t':~Mi~'i"idRY ~(D~-ttliltYf ~sa~wrc~wt+o+tzw~awu,,~utua~ •wrl- R°_ ~~5243 Contract !~ ~ ~ ` ~ ~~ CEMETERY INTERMENT File Folder NatneJNumber AND SERVICES PURCHASE/SECURITY AGREEMENT -------- The uadersigttd, refeerad b p `P4Khaaer', hereby agrees b purchafe the IaterraeM Righra, Merchandise and Services deurl6ed herei4 wbjeet b aecaptaae! and approval d the sbovs mined centelery, hereafter referred b af'SeRer'. Purchaser. Last Name: ~~~..tt ,~ I I I J I I 1 1 1 1 1 1 1 First: Q ~~~ ~ A 1 1 1 1 1 1 1 1 Middle; (. I f I I I I Telephone: {~. (pQ~ tp43 ,, SSN: DOB: ._/_!~ Email: Address: t A r ~ t. r ,t~w w, a, .\ h ~ h o i ~ ~ t ~ ~ r ~ t r t City $3 ie C 1i tts R) t /Y_O R 11 fdf1 Stain: i.1 R I Zip: t ~.~ ~ ---- Co•Purchaaar: t.ast Nama: I I I I I 1 1 1 1 1 1 1 1 1 1 1 1 1 First: ~• I I I 1 1 1 1 1 1 1 1 1 Middle' I l l I l j l Telephone: (~~ _ SSN: _ DOB: _1 f Email: Addrcaa; 1 1 1 1 1 1 1 I f l l l l I I I I 1 1 1 1 1 1 1 11 City: ~ I I l 1 1 1 1 1 1 I I I State: LL1 Zip: Deceaed: laut Noma: ~ ~~~ C O Q ~ I 1 I. I 11 .. Middle: I: ~1 l 11 Q' iZ l Y~ 1 I I t -r, L ~. 11 I f 1 I ,~~ ~= L_~ DOR' -~ ~ ! f a t Iqb~ DOD; ! :~. /01(0 1, n'~411 Burial Datc:'~ '~ ~! ~ / _R /v II Vereren: Deacrlptko or laterraeat Rfgbts to he uses: .121 ~ • Q "Srrl . rnA ! S! C ~il- MHOO$~j~~°°~_ Rte: Issue Certificate of tnarmera Rights to: Addrcu: City: State: Zip: INTERMENT. [ • InttrTrreM Rights S '~ (htcludes Perpetual/EndowmeN Care of S ) • Interment and Recording Fees 1 3 45 , • Outsr Burial Container Supplier ModeltDesign MateriaUColor • Onher Burlyd CoMalaer Installation "•" MEMORIALIZATION • Memorial '- Supplier TypetCobr DesigntSize • MemoriM Base '~ Supplier TypeJColor Design/Size • Memorial perpetualJEndowraenl Cart • Memorial Instalhrtba Fee • Memtu`ial laspectlots Fee • NameplMeJScroll • Lettering ` • Flower Yale Supplier TypelColor DesigatSiu • Vase Base Sii:e/Material . ,~ Notts & Payment Terms (where applkabk): • Urn .r ~ -- Suppikr ~ TypetCobr`` DesjgnlSi _. • AdminlP ng Fee • Othxr ; _. • Other _ • Other • Other • Other • Other TOTALS, ALLOWANCES & TAXES • Interment Rig6ts .....................................................r......... ( •' ) Bassos - • lylerchaadkelStrvlrx ......:................................................. ( ) Reason ,_ Apply to • MerchandlsefServhx ........................................................ ( -- ) Reason. Apply to _. ^~ Sub ToW ! S41 • r'A~ Total Taxable '- • Sala Tax (If appUcabk) ................................................... TOTAL CASH PRICE f ! Z Q 'r • ~ Less: Down Payment ,~,~ Other , """~ Total Dawn Paymsat (~ ) ~ Unpaid Bahtttce of Tots! Cash Peks S .~.~- -- TERMS The Ttrtal Cash Prke is due and payable as of the date of this Agreemem. A delinquency charge of percent will be assessed mon[hly on any balance not paid within 30 days of the date of this Agreement. If ku then full payment is received. Seller shat! deduct the accrued delinquency charge from the amount received and credit the remainder of the payment to tha Unpaid Balance. SecurRy 1Mtwestt Sailer (or its assign0 will have a security intereu in fhe latertuem Rights acrd Merchandise being purchased as described about. Seller will retain title to said Interment Rights and Merchandise until the Taal Cash Price, together with any delinquency charges thereon. have been paid by Purchase to Seller. NOTICE: By signing this Agreement, Purchaser is agreeing that any claim Purchaser may have against the Seller shall be resolved by arbitration and Purchaser is giving up histher right to a court or jury [vial as well as hisfher right of appeal. Signed this ~_ day of f~._ , 20 l ~ ~ Purchaser: n Relationship: y~,~t7~'tt.tr Co-Purchaser. Relationship: ~ ~/ I1 , , Counselor. - •" ~^ 'NOTICE: See Other Side [or Additional Terras and Conditions which are Part of This Agreement am J azaJ RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Receipt Date: Cumberland County - Register Of Wills Receipt Time: One Courthouse Square Receipt No.: Carlisle, PA 17613 FRITZ JEFFREY A Estate File No.: 2011-00316 Paid By Remarks: CAUp INGHAM & CHERNICOFF PC ________________________ Receipt Distribution 3/09/2011 12:38:22 1064718 FeefTax Description Payment Amount Payee Name PETITION LTRS ADM 45.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 20.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 -------------- CUMBERLAND COUNTY GENERAL FUN Check# 12980 -- 593.50 Total Received......... $93.50 REV 1737.7 EX + (6-0S) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN NONRESIDENT DECEDENT scNEOU~E ~ pEBTS OF pECEOENT use soneauie i, Part 2, ONLY for MORT~iAQ~E LIABILfT1ES, & LIENS proportionate method of tax computation. ESTATE OF Jeffrey A. Fritr FILE NUMBER Part 1 must include mortgage liabilities, liens and taxes against the Pennsylvania realty that were due and owed as of the date of decedent's death. Complete Part 2 ONLY when the proportionate method of tax computation is elected. ITEM NUMBER DESCRIPTION AMOUNT 1. TarwL pwwr ~ $ o.a ITEM NUMBER DESCRIPTION AMOUNT ~ • Verizon Wireless 48.43 2. Pittman & Associates (Nursing Care) 1,585.00 3. Capital One 109.99 4. Visiting Angels 1,130.00 5. PPL 187.84 g. Penn Rehab Associates 299.90 7. Junk Removal from Apartment 420.00 TOTAL PART s $ 3,781.1 F TOTAL (Also enter on Line 10, Recapitulation.) $ 3,781.1E (if more space is needed, use additional sheets of paper of the same size) . ~ ,. L/ Vi~!"IZOtlwit~e/eas f Manage Your Account & crew Your Usage Details ;Account Number ~ Date Due PO BOX 4003 ACWORTH, GA 30101 ~~ ., . . ~ ,_ (Invoice Number !6545686137 1001 0083 Ot AT 0.357 "AUTO (TS 0 7225 17043-194565 7 5 E PHIL2504 (111(((111(((1111(ii(11((Iill(j(Ililljll(i(1(11((111 (!(tl(1(I( JEFFREY A FRITZ 65 HUMMEL AVE LEMOYNE, PA 17043-1945 ~~~~ Save Time And Money It's never been easier to enroll in Auto ~ Bill Pay. See back of Payment Coupon ', below for details. Quick Biil Summary Jan 26 -Feb 25 Previous Balance (see back for details $146.54 Payments -Thank You -$114.96 Adjustments -$109.85 Credit Balance _ST827 Monthly Access Charges $110.16 Usage Charges Voice $.00 Messaging $,p0 Verizon Wireless' Surcharges and Other Charges & Credits $S.gg Taxes, Governmental Surcharges & Fees $7.55 Total Current Charges $126.7Q Total Charges Due by March 20, 2011 $48.43 from Wireless j Pay on the Web ;Questions: r- 1,,,/" It@/'fZOllwrnaless Invoice Number Account Number Date Due Page 6545686137 720968!15-Od001 43/2Dt1t 3 of4 Summary for Jeffrey Fritr: 7i7-350-OA01 Your Calling Plan Natbnwide Talk 450 $39.99 monthly access charge 450 monthly allowance minutes $.45 per minute after allowance M2M National UnNmited Unlimited Mobile to Mobile UNL Nigh & Weekend Min Unlimited OFFPEAK Pay As You Use Megabyte Data $1.99 per megabyte 500 MSG Alowance + UNL iN MSG $10.00 monthly access charge Unlimited monthly M2M Text Unlimited monthly M2M PIX & Video 500 monthly message allowance $.10 per message after allowance Have more questions about your charges? Get details for all your Usage Charges at www.verizonwireless.com. Sign into My Verizon and go to My Bill and click on Usage Details. Taxes, Governmental Surcharges and Fees PA State Wireless E911 Surchg PA State Sales Tax Total Currertt Charges for 717-350-0401 Charges Monthly Access Charges Nationwide Talk 450 01/27 - 02!25 Nationwide Talk 450 02!26 - 03!25 TEC Insurance - Asurion 01/27 - 02!25 TEC Insurance - Asurion 02126 - 03125 500 MSG Allowance +UNL IN MSG 01127 - 02125 500 MSG Allowance + UNL IN MSG 02!26 - 03!25 ~~~~d 38.70 39.99 5.80 5.99 9.68 10.00 1.00 6.55 $7.55 $126.70 $11D.1s Usage Charges Voice Allowance Used Billable Cost Calling Plan minutes 450 2 -- -- Mobile to Mobile minutes unlimited 14 -- -- Total Voice $,00 Messaging Unlimited M2M Text messages unlimited 1 -- -- Text, Picture & Video messages 500 2 -- -- Total Messaging $.00 .Total Usage Charges $.00 Verizon Wireless' Surcharges Fed Universal Service Charge 2.68 Regulatory Charge .13 Administrative Charge .83 PA Gross Receipt Surchg 5.35 $8.99 Pittman & Associates, Inc. One Prescott South P. O. Box t j 1047 Memphis, TN 38i 11 Electronic Service Requested 3-DIGIT 170 7442 0.3584 AT 0.362 Ill~lllllllilllllltllln`1,Ilu~rlll'1~'lll~lll~~~'~~II11"{Iri~l JEFFREY FRITZ 48 306 W40DLAND DR ItECHANICSBURG, PA 17U55-3372 Monthly F_rplanation of Benefits - This is not a B1U JEFFREY FR[TZ ~ v& AS~OC;ZA~IN+~ r~llw~~,l3s Questions? Contact us: Toll Free: Ali Claims(800) 238-{344 Local: 901-473-3100 Customer Svc Hrs: Mon-Fri 8:00 am to 5:00 pm CT Website: http:!lwww.pa-tpa.com SIiELBY GROUP INTERNATIONAL, INC. Group Number G218 Member ID # 100180821 Issue Date (13/28!2011 Page 1 of 1 F r u Patient's Name Type of Service Service Date(s) Billed Charges Discount Amount Other Adjust- Other Plaa Patient Responsibility Benefit Amount Plaa Paid Reason Code ments Payment Ineligible Co-Pay Deduct OOP At Patient Name: JEFFREY Claim Number: 1 tOb360401 Provider: CENTRAL MEDICAL EQUIPMENT Finalized: 04!15120! 1 INELIGIBLE 01/24/2011 185.00 0.00 0.00 0.00 185.00 0.00 0.00 0.00 0.00 0 IE iNEL[GI LE 01/2AJ2011 50.00 0.00 0.00 0.00 50.00 0.00 0• 0.00 0.00 0 1NELIGIBL 0!!2412011 25.00 0.00 0.00 0.00 25.00 0.00 0.00 0.00 0.00 0 IE !Orals: GOV.w v.w v.w V.w tw.w v.VV v.w v.w v.+sv PATIENT RESPONSIBILITY 260.00 Patient Name: JEFFREY Claim Number: 1106481401 Provider: '""'UNASSIGNED PROVIDER""• Finalized: 04/i5/2011 INELIGIBLE 02/01/2011 750.00 0.00 0.00 0.00 750.00 0.00 0.00 0.00 0.00 0 m Totals: 750.00 0.00 0.0~ 0.50.00 0.00 0.00 0.00 0.00 PATIENT RESPONSIBILITY 750.00 Patient Name: JEFFREY Claim Number: t 106482001 Provider: *"•'UNASSIGNED PROVIDER*"" Finalized: 04!15!201 I INELIGIBLE 02116/2011 575.00 0.00 0.00 0.00 575.00 0.00 0.00 0.00 0.00 0 1E Totals: 575.00 0.00 0.00 0.00 575.00 0,00 0.00 0.00 0.00 PATIENT RESPONS[BILiTY 575.00 Your ne:t monthly explanation of benefits, if any claims are processed, will arrive the week of: OS108l2011 ,~r_""'!-" Electronic EOB's are now available? When medical claims have been paid for any family member you may receive your family EOB via your personal e-mail address. To enroll simply a-mail your first and last name, date of birth, member identification number, group number (listed on your identification card), and email address to lnfo[)Sa-1 aR com. Reason Code Descriptions: IE This serviceJsupp{y is ineligible under your plan. If you disagree with this determination, you must submit proof that the claim for benefits is covered and payable under the Plan's provisions, including (a} all facts and theories supporting your claim, (b) a statement of the reason(s) for disagreement with the handling of the claim, and (c) any materiaUinfornation that indicates that the claim does not fall within the referenced Plan provision. This Plan allows for 2 appeals of an adverse benefit determination. Each appeal provides full and fair review of an adverse determination in compliance with the Employee Retirement Income Security Act of 1974 ("FRIBA") and the regulations issued thereunder. The claimant or claimant's authorized representative has 180 days from receipt of this notice to file the first appeal and 60 days to file the second appeal. Appeals may be mailed to Pittman Br Associates, PO Box 111047, Memphis, TN 38111. For additional questions regarding the claimant's appeal process, please call901-473-3100 or 800-238-1344 and speak with a customer service .~ r n O s r i ~ $ _~ ~ ~. $ _ t ~ $ a ~. ~ ~. 1~_ Z. :;--~ ' ~ ~~ 11 ~, .., ~,'- ~8 ~ ~ ~ ~~ ~ ~ ~ ~~ ~ ~~ ~. ~ ~ ~ ~~ ~~ + _`~. `W` ~.7 1~ Q O V r ~ M y~ r ~ w w '~ ~ ~ ~ ~ ~ ~$ ~ V 1 v T V m d ~ M~~ ~ ~ a r ~" ~n N i d ~ ~ d 0 sh ~ h ~ ~ ~ w ~ ~ ~ ~ ~ ~ a Z~ d N = •~ M v 4 ~ M _ ~ ~ ^~ } ± Y~ N 3 c .,,, ,9' ~ in o a `+ ~ d r. == rn~ ~~ ~_ o ~~ ~ o ~~ ~ . as ,~ ~~~ ~~Z ~~ °~ ... ... E 1~/! a ~ ~ s W v a"~ 2 t ~ '~ ~, `{ ~ 1~ -`` f~ it f {[~ 7 os N 88 N H ~o ~~ ^~ N $$ 8$ ~8 _ o0 0 M M V^~- ~M A N s g :~~ ~~ ~~ ~~ ~ ~~ ~~ ~~ ~ ~~ ~~ ~ ~ ~~ ~ <~~ s °~~ Z ~~ ~~ W C ~~ ~~ ~ ~ _~ ~~ ~ c eWc '~ ~ ~ 1 fir, Senior Ho~necam By Visiting Ange/s(§1 9a N Progress Ave Harrisburg Pa 17109 Phone 717-652-8899 Fax 717-909-3185 Jeffrey Fritz 106 Woodland Dr Mechanicsburg Pa 17055 ~, ~~sGt`_ ...sAngelsti ~~~IVfN6 ASS{S7ANCE SERVICES DATE: FEBRUARY 15, 2011 DESCRIPTION HOURS RATE AMOUNT Invoice for service February 1"-15`" 2011 2/1/11 Bana Sackey Sam-gam 2/1/11 Bana Sackey 8pm-9pm 2J3i11 Bana Sackey Sam-gam 2/3/11 Bana Sackey 8pm-9pm 2/4J11 Bana Sackey Sam-gam 2/4/11 Bana Sackey 8pm-9pm 2J5/il Bana Sackey Sam-gam 2/5/11 Bana Sackey 8pm-9pm 2/6/11 Bana Sackey Sam-gam 2J6/11 Bana Sackey 8pm-9pm 2J7J11 Bana Sackey Sam-gam 2J7/11 Bana Sackey 8pm-9pm 2/8/11 Bana Sackey Sam-gam 2J8J11 Bana Sackey 8pm-9pm 30 $25.00 $750.00 2/9J11 Bana Sackey Sam-gam 2J9/11 Bana Sackey Bpm-9pm 2/50/11 Bana Sackey Sam-gam 2/lOlii Bana Sackey 8pm-9pm 2Ji1/li Bana Sackey Sam-gam 2/11J11 Bana Sackey 8pm-9pm 2/12/11 Bana Sackey Sam-gam 2/12/11 Bana Sackey 8pm-9pm 2/13/11 Bana Sackey Sam-gam 2/13/11 Bana Sackey 8pm-9pm 2/14J11 Bana Sackey Sam-gam 2/14/11 Bana Sackey 8pm-9pm 2J15J11 Bana Sackey Sam-gam 2/15/11 Bana Sackey 8pm-9pm TOTAL $750.00 It's been our pleasure providing homecare services to your family! ,~~ F. Senior Homecaro By Visiting Ange/s@ 9a N Progress Ave Harrisburg Pa 17109 Phone 717-b52-8899 Fax 717-909-3185 Jeffrey Fritz 106 Woodland Dr Mechanicsburg Pa 17055 V~stt' Angels,. ~~~MNG A9913TA11CE SERVICES ~ ~~., DATE: FEBRUARY 15, 2011 DESCRIPTION HOURS RATE AMOUNT Invoice for service February 1'~-15"' 2011 2/1/11 Bana Sackey Sam-gam 2/1/11 Bana Sackey Spm-9pm 2/3/11 Bana Sackey Sam-gam 2/3/11 Bana Sackey Spm-9pm 2/4/11 Bana Sackey Sam-gam 2/4/11 Bana Sackey Spm-9pm 2/5/11 Bana Sackey Sam-gam 2/5/11 Bana Sackey Spm-9pm 2/b/31 Bana Sackey Sam-gam 2/6/11 Bana Sackey Spm-9pm 2/7/11 Bana Sackey Sam-gam 2/7/11 Bana Sackey Spm-9pm 2/8/11 Bana Sackey Sam-gam 2/8/11 Bana Sackey Spm-9pm 30 $5.00 $150.00 2/9/11 Bana Sackey Sam-gam 2/9/11 Bana Sackey Spm-9pm 2J10/11 Bana Sackey Sam-gam 2/10/11 Bana Sackey Spm-9pm 2/1l/1l Bana Sackey Sam-gam 2/i!/11 Bana Sackey Spm-9pm 2/12/11 Bana Sackey Sam-gam 2/12/11 Bana Sackey Spm-9pm 2/13!11 Bana Sackey Sam-gam 2/13/11 Bana Sackey Spm-9pm 2!14/11 Bana Sackey Sam-gam 2/14/11 Bana Sackey Spm-9pm 2/15/11 Bana Sackey Sam-gam 2/15/11 Bana Sackey Spm-9pm ~~~'` ~L' ~, t~ 3 30 TOTAL $150.00 ,~ s peen our p~easure proviaing nomecare services to your ramny! ~, 'Senior Homecare By Visiting Angeism 9a N Progress Ave Harrisburg Pa 17109 Phone 717-652-8899 Fax 717-909-3185 Jaffrey Fritz 106 Woodland Dr Mechanicsburg Pa 17055 A {~~s' ~ , A,nge ls. ~}~ . _ n , _ _~._~. liViN6 A88181ANCE SERVICEB DATE: MARCH 3, 2011 DESCRIPTION HOURS RATE AMOUNT Invoice for service February 16u' -28u' 2011 2/16/11 Bana Sackey 8pm-9pm 2/17J11 Bana Sackey Sam-gam 2/17/11 Bana Sackey 8pm-9pm 2/18/11 Bana Sackey Sam-gam 2/18/11 Bana Sackey 8pm-9pm 2/19/11 Bana Sackey Sam-gam 2/19/11 Bana Sackey 8pm-9pm 2/20/11 Bana Sackey Sam-gam 2/20/11 Bana Sackey 8pm-9pm 2/21/11 Bana Sackey Sam-gam 23 $5.00 $115.00 2/21/11 Bana Sackey 8pm-9pm 2/22/11 Bana Sackey Sam-gam 2/22/11 Bana Sackey 8pm-9pm 2/23/11 Bana Sackey Sam-gam 2/23/11 Bana Sackey 8pm-9pm 2/24/11 Kofl Berko Sam-gam 2/24/11 Kofl Berko 8:45p-9:45p 2/24/11 Kofi Berko Sam-gam 2/24/11 Kofi Berko 8:45p-9:45p 2/25/11 Kofi Berke Sam-gam 2/25/11 Kofi Berko 8:45p-9:45p 2/26/1] Kofi Berko Sam-gam 2/26/11 Kofi Berko 8:45p-9:45p TOTAL #115.00 ~ Senior Hamecare By Visiting Angels® 9a N Progress Ave Harrisburg Pa 17109 Phone 717-652-8899 Fax 717-909-3185 Jeffrey Fritz 106 Woodland Dr Mechanicsburg Pa 17055 .angels, ; -:~ ~V~ ' t _ _ ~~~ ~^~~1VIH6A8318TANCESERVICE9 *e, DATE: MARCH 8, 2011 DESCRIPTION HOURS RATE AMOUNT Invoice for service February 16« -28a' 2011 2J16J11 Bana Sackey 8pm-9pm 2J17J11 Bana Sackey Sam-gam 2/17J11 Bana Sackey 8pm-9pm 2/18/11 Bana Sackey Sam-gam 2Ji8/11 Bana Sackey 8pm-9pm 2J19/li Bana Sackey Sam-gam 2J19J11 Bana Sackey 8pm-9pm 2J20/11 Bana Sackey Sam-gam 2/20J11 Bana Sackey 8pm-9pm 2/21/11 Bana Sackey Sam-gam 23 $5.00 $115.00 2J21J11 Bana Sackey 8pm-9pm 2J22J11 Bana Sackey Sam-gam 2/22Ji1 Bana Sackey 8pm-9pm 2J23/11 Bana Sackey Sam-gam 2/23/11 Bana Sackey 8pm-9pm 2J24/il Kofi Berko Sam-gam 2/24J11 Kofi Berko 8:45p-9:45p 2J24Ji1 Kofi Berko Sam-gam 2/24/11 Kofi Berko 8:45p-9:45p 2/25J31 Kofi Berko Sam-gam 2/25/11 Kofi Berko 8:45p-9:45p 2/26J11 Kofi Berko Sam-gam 2/26/11 Kofi Berko 8:45p-9:45p TOTAL ~i15A0 PPL Electric Utilities Electric Service For: JEFFREY A FRiTZ 65 i-j[IMMEL AVE LEMOYNE PA 1"7043 Questions about this bill? Please contact us by Feb 28 at 1-SdU-342-5775 (1-8Q0-DIAL-PPL) or write to: Customer Service 827 Hausman Rd A1leyrtown, PA 18104-9392 www.pl~lelecbric.com Electric Use This gxaph shows your electric use oven the last 13 months- Types of Meter Readings: Actual - Adjusted '~ Estimated Customer C] ~ 1 ~ I• ;- :--~ ~~ rs-n .~ .. Summary Page Balance as of Feb 7, 2011 Chaz es: 14.32 Tota~PL Electric Utilities Charges $ Total Dotrumc~J Energy Solutions Charges $15.11 Total Charges $29.43 yam, y~ :: ~. ~ ~' ~ ~~ $29 43 Account Balance Page 1 :<iac 131 ..-,r.,,,,,,~~-_,- 83450-82026 $0,00 ~3 zZ 6(? 50 40 30 20 l0 0 KWH -Average Per Day Meter Reading Information Meter #47122633 Feb 4 Actual 60382 Jan 6 Actual 60212 29 Da s KWH Billed 170 a Ave r ge -Feb 2 2 31 F m p e P ` 26F 6 er Day S3 K NH Yearly Use: Total Avera e tJse Mont>~ Mar 2009 -Feb 2010 8395 70 Mar 2010 -Feb 2011 5456 455 FMAMJ JASCJNDJF 2010 Months 201 ! PPL Electric Utilities Electric Service For: JEFFREY A FRIZZ 65 FITJMMEL AVE LEMOYIJE PA 17043 Dominion Energy Solutions Customer Service P O BOX 298 PITTSBURGH, PA 15230 1-88~Z16-3721 PPL Electric Utilities Customer Service 827 Hausman. Rd. Allentown, PA 18104-9392 1-800-341-5775 (1-800-DIAL-PPL) www.pplelectric.com ~~ t ~ ~ ~~~ r ~•: "'•:•;-' . _ Page 3 - ,~:.~~ . 133450-82026 , ,~ Total from Last Bill $29.43 Payment Received Feb l6 -Thank YoW! $29.43 Billing Details Balance as of Mar 9, 2011 $0.00 Current Charges Charges for -Dominion Ene Solutions General Service Rate: DOMPP~for Feb 4 -Mar 8 Electric Chg - 390 Kwh ~~ .0889 34.67 Electric Chg - 109 Kwh .0889 9.69 Gross Receipts Tax $2.5 Esfimated Pa State Taa $0.00 Total Dominion Energy Solutions Charges Current Charges Charges for -PPL Electric Utilities Residential Rate: RS for Feb 4 -Mar 8 Distribution Chazge: Customer Charge 200 KWH at 3.30000000¢ per KWH 299 KWH at 3.30000000¢ per KWH PA Tax Adj 5urchazge at -0.27600000% Total PPL Electric Utilities Charges Account Balance $44.36 $69.51 General Generation prices and charges are set by the electric generation supplier you have chosen. The Public Utility Commission re ates distribution Information rites and services. The Federal Energy Regulatory~ommission regulates t ransmission prices and services. Neat meter reading on or about PPL Electric Utilities uses about $0.03 of this bill to ~ppaay state taxes. In addition, about $1.48 of this bill pays the PA Gross ltecerpts Tax. Apr 6 For our convenience, you can now pa your bill using your Visa, Mas~erCazd, Discover, or ATM Card all BiDMatrix at 1-80()-672-2413. Bi1lMatrix will charge your credit and ATM cazd a service fee for making this payment. Before digging around your home or property, you should always call the state's One Call notification system to locate any underground utility lines. You can do this by simpl dialing 811, which will connect you to the One Call system. Be safe andYcall 81I before you dig. With pa rless billing, you can receive and pay your PPL Electric Utilities bills onl-me. The process is &ee, quick, canvement and secure. To learn more or sign up, visit www.pplelectnc.com. Save postage and late charges -sign up for Automated Bill Payment. Clean the coils on the back or bottom of your refrigerator every 3 months. llust covered coils waste energy. PPL Elsc#ric V#111#IeS Electric Service For: JEFFREY A Fxrrz 65 HCJMMBL AVE LEMOYtYE PA 17043 Questions about this bill? Please contact us Mar 30 at 100-.34 -5775 (1-800-DIAL-PPL) or write to: Customer Service 827 Hausman Rd. Allentown, PA 18104-9392 www.pplelectric.com Electric Use This graph_shows your electric use over the last l3 months. T of eter Readings: Actual . Adjusted Estimated Customer 0 ~~ ~ t ~'.'~~''.' - ` Page 1 _ . :,,, • 83450-82026 . aer as "vr:wF Summary Page Balance as of Mar 9, 2011 $(1.00 Chargge_~s: TotaCYPL Electric Utilities Charges $25.15 Total Dominion Energy Solutions Charges $44..36 Total Charges $69.51 Account Balance $69.51 lS~ ~ J Meter Reading Information KWH -Average Per Day 50 40 30 20 l0 0 Meter #47122633 Mar 8 Actual 60881 Feb 4 Actual 60382 32 Da s KWH Billed - 499 Average -Mar 2010 2011 Temperature 33F 35F KWH Per Day 51 16 Yearly Uae: Total Averaagge 1Jse MontWy Apr 2009 -Mar 2010 8650 72l Apr ZO10 -Mar 201 I 4324 360 MAMJJA5ONDJFM 2010 Months ZOII Other important information on back 3 PPL Electric Ut1I1t1e5 Electric Service For: JEFFREY A FRITZ 65 RUNNEL AVE LEMOYNE PA 17043 Finest Bitl Questions about this bill? Please contact us by Apr 12 at 1-800-342-5775 (1-800-DIAL.-PPL) or write to: Customer Service 827 Hausman Rd. Allentown, PA 18104-9392 www.pplelectric_cam Electric Use This graph shows your electric use over the last 13 months. Types of Meter Readings: Actual Adjusted Estimated Customer (~ :p .c i 1' ~°a~a a a'~T~n " Page 1 r ~p~ ~-~- Summary Page Balance as of Mar 22, 2011 Charges: ~,f ~~ ~-1 ~ Tat omtttton Energgyy Solutions Charges $29.96 Total PPL Electric Uhiities Charges $14.58 "Total Charges $114A5 :.:: . `~`. ~;111dp~~lt'1# 1~,1~.,~~~; >~l~ls:..: if` ~:.. ~11~1r ......:.. . :..... ,.:.... '~. ~~~..:. Account Balance $114.05 ~~ (~''~CJ l.S% KVVH -Average Per Day 36 30 24 18 12 6 0 AMJJASONDJFMA 2010 Months 2011 Meter Reading Information Meter #47122633 Mar 20 Actual 61 Z 18 Mar 8 Actual 60881 _ 12 Da s KWH Billed 337 Average -Mar 2010 2011 Teetttt~~pperature 52F 45F KWH Per Day 25 28 Yearly Use: Total Average Use Monthly Apr 2009 -Mar 2010 8606 717 Apr 2010 -Mar 2011 3919 327 R345(1_R~(l7~ Other important information on back ~ tPENN REHAB ASSOCS STATEMENT '"~" 2151 LINGLESTOWN ROAD SUITE 240 HARRISBURG,PA 17110-9453 Patient: FRITZ,JEFFREY A Tax I.D. 232161.606 Tel: 7175419970 STATEMENT DATE PAGE FRITZ, JEFFREY A 3~ ~j 02/01/11 1 65 HUMMEL ST !p LEMOYNE,PA 17043 ACCOUNT NUMBER 10019669 - 1 / CM INDICATE AMOUNT PAID $ r Place Codes: IH=Tn Patient OH=Out Patient ER=Emergency Room ------------- DATE ~ICD9 ------------- ----------------- CD~PL*~ ----------------- ------------------ DESCRIPTION ------------------ -------------------- ~ AMGUNT -------------------- 10/12/10 12/29/10 12/29/10 10/13/10 12j29/10 12/29/10 10/14/10 12/29/10 12/29/10 10/15/10 12/29/10 12/29/10 X10/16/10 112/29/10 12/29/101 10/17/10~~ 12/29/10 12/29/10 10/18/10 12/29/10 12/29/10 10/19/10 12/29/10 IH ~IIH IH IH IH IH TH IH (Balance forward last statement x,99222 INPATIENT HOSPITAL CARE INCK INSURANCE CHECK INWO INSURANCE WRITE OFF 99231 SUBSEQUENT HOSPITAL CARE INCK INSURANCE CHECK INWO INSURANCE WRITE OFF 99231 SUBSEQUENT HOSPITAL CARE INCK INSURANCE CHECK INWO INSURANCE WRITE OFF 99231 SUBSEQUENT HOSPITAL CARE INCK INSURANCE CHECK INWO INSURANCE WRITE OFF 99231 SUBSEQUENT HOSPITAL CARE INCK INSURANCE CHECK INWO INSURANCE WRITE OFF 99231 SUBSEQUENT HOSPITAL CARE INCK INSURANCE CHECK INWO INSURANCE WRITE OFF 99231 SUBSEQUENT HOSPITAL CARE INCK INSURANCE CHECK INWO INSURANCE WRITE OFF 99233 SUBSEQUENT HOSPITAL CARE INCK INSURANCE CHECK Continued on page 2 0.00 198.00 -85.03 -56.28 72.00 -26.04 -28.60 72.00 -23.67 -32.55 72.00 -23.67 -32.55 72.00 -23.67 -32.55 72.00 -23.6? -32.55 72.00 -23.67 -32.55 109.00 -35.83 ------- CURRENT ----------- AMOUNT -- --------- PAST DUE --------- AM --- --------------------------- S ( O.QO I THIS AMOUNT I$ 299.90 l~ ~~ ~~~ ~ aPENN REHAB ASSOCS STATEMENT "'" 2151 LINGLESTOWN ROAD SUITE 240 HARRISBURG,PA 17110-9453 Patient: FRITZ,JEFFREY A Tax I.D. 232161606 Tel: 7175419970 STATEMENT DATE PAGE FRITZ,JEFFREY A 02/01/11 2 65 HUMMEL ST LEMOYNE,PA 17043 ACCOUNT NUMBER 10019669 - 1 / CM INDICATE AMOUNT PAID $ Place Codes: IH=In Patient OH=Out Patient ER=Emergency Room DATE `ICD9 CD~PL*~ DESCRIPTION ~ AMOU~:T 12/29/10 INWO INSURANCE WRITE OFF -49.28 10/20/10 IH 99231 SUBSEQUENT HOSPITAL CARE 72.00 12/29/10 INCK INSURANCE CHECK -23.67 12/29/10 INWO INSURANCE WRITE OFF -32.55 10/21/10 IH 99231 SUBSEQUENT HOSPITAL CARE 72.00 12/29/10 INCK INSURANCE CHECK -23.67 12/29/10 INWO INSURANCE WRITE OFF -32.55 10/22/10 IH 99232 SUBSEQUENT HOSPITAL CARE 94.00 12/29/10 INCK INSURANCE CHECK -30.90 12/29/10 INWO INSURANCE WRITE OFF -42.50 10/23/10 IH 99238 HOSPITAL DISCHARGE DAY 132.00 12/29/10 INCK INSURANCE CHECK -49.94 12/29/10 INWO INSURANCE WRITE OFF -48.76 11/19/10 O 99213 EXPANDED PROBLEM H&P 94.00 12/29/10 INCK INSURANCE CHECK -56.40 O1/06j11 PATIENT RESPONSIBILITY 299.90. -------- CURRENT ---------- AMOUNT -- ---------- PAST DUE ----------- AM --------------------------- S ( 0.00 I THIS AMOUNTI $ 299.90 REV-1737-7 EX + (6-OB) REVERSE ~ Pennsylvania DEPARTMENT OFREVENUE INHERITANCE TAX RETURN NONRESIDENT DECEDENT SCNEp11LE J BENEFICIARIlS ESTATE OF FILE NUMBER Jeffrey A. Fritz When flat rate method is elected, list the beneficiaries of the Pennsylvania property. When proportionate method is elected, list all beneficiaries. RELATIONSHIP TO ITEM DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Ust Trustees) OF ESTATE j, TAXABLE DISTRIBUTIONS [indude outright spousal distributions and transfers under Sac. 2116 (a)(1.2)j 1. Bonnie S. Fritz, 106 E. Woodland Dr., Mechanicsburg, PA17055 Mother 100.00 ENTER DOLLARAMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON REV•1737 COVER SHEET OR THE PROPORTIONATE METHOD WORKSHEET ON THE REVERSE SIDE OF REV-1737 COVER SHEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. roTw~. o~ Pwlliirir a (Enter total non-taxable distributions on Line 13 of REV 1737 cover sheet.) ;100.00 (If more space is needed, use additional sheets of paper of the same size)